Contact

First Name

Last Name

Date of Birth

Pronouns

We ask about gender identity and race as this information will help us identify practitioners who may specialize in working with these identities.

Gender Identity

Gender for Insurance

Race/Ethnic Background

Email Address

Best way for a care coordinator to contact you to get you connected to a therapist:

Email Phone Either

Phone

OK to leave a message?

Yes No

Insurance Provider

Insurance Number

Is your insurance Medicare?

Yes

Reason you are seeking services

Therapist You'd Like to Work With:

In the past 2 years, have you experienced suicidal thoughts, or made a suicidal threat or attempt?

Yes

Do you or your loved ones have any concerns about your use of alcohol, recreational drugs, or any other substance?

Yes

If Yes, what substances and how often are you using them?

Do you have any accessibility needs that we should know about before your first appointment?

Current enrollment in other services?

Have you ever been hospitalized or treated at a higher level of care for a mental health condition?

Yes

If Yes, when and for what?

Do you have any concerns about your personal safety or well-being: such as insecure access to resources like housing, food or health care, and/or exposure to unsafe behaviors in your home?

Yes

If Yes, what concerns do you have?

Contact Our Office

Healing Tides Counseling

2450 SE Belmont Ave,
Portland, Or 97214
971-910-8918

We believe therapy should be accessible for everyone. If you are experiencing financial barriers, please contact us so that we can support you in finding solutions.

Contact Our Office

Healing Tides Counseling

2450 SE Belmont Ave,Portland, Or 97214971-910-8918

We believe therapy should be accessible for everyone. If you are experiencing financial barriers, please contact us so that we can support you in finding solutions.

2450 SE Belmont Ave,
Portland, Or 97214
971-910-8918